2018-19 TOW #26: Childhood Obesity

As the new year begins, we can harness the season’s focus on wellness to offer families encouragement with healthy behaviors. Obesity prevention and intervention is a topic close to my heart, so I am excited to highlight our great local resources. We have many wonderful obesity research experts in our clinics, including Drs. Lenna Liu, Jay Mendoza, and Pooja Tandon. A big thanks to Dr. Allison LaRoche for her help updating materials for this topic. Feel free to email any of us with questions!

Teaching materials for this week:

Take-home points for this week:

  1. What’s the epidemiology of child obesity?: While some progress is being made, with promising data on declines among preschool youth, overweight/obesity rates remain high at 1 in 3 children with a BMI at or above the 85th percentile. Etiology of obesity is multifactorial including important environmental contributors that are affected by social determinants. As pediatricians, we should acknowledge the equity issues reflected in higher rates of obesity among those with more social disadvantage including low-income families, and Hispanic, African American and American Indian youth.
  2. What focused messages can we share in clinic? Focusing on behaviors/ environments that support healthy weight starts from infancy. Teach the Division of Responsibility for feeding in which “parents provide, and child decides.” The parent is responsible for what, where, and when food is served, and the child is responsible for how much to eat. We can use 5210 goals to help guide healthy weight behaviors: 5 fruits and veggies per day, watch no more than 2 hours of screen time, get 1 hour or more of physical activity, and have 0 sugary drinks. The Let’s Go! 5210 campaign was started by a pediatrician in Maine, and they have some great resources like Phrases that Help and Hinder. Families should choose their own goals through motivational interviewing, which has been shown in randomized trials in pediatrics to work in improving weight trajectories.
  3. How can we address this sensitive topic and avoid weight stigma in our practice? Recognize that obesity is highly stigmatizing and bias for weight is among the strongest biases culturally, even among children. We must be aware of our own biases as we treat patients and adopt inclusive, non-judgmental language, as recommended by Health at Every Size (HAES), which seeks to promote health-affirming behaviors and diversity of size, and to decrease weight stigma and emphasis. It’s helpful to acknowledge there are a lot of things outside the control of families (genes, community environment, etc), while also supporting specific behaviors that make a difference for health.
  4. What are the approaches for overweight and obese? For youth with BMI >85th percentile (overweight), and BMI> 95th percentile (obese), follow weight trajectory and family history to assess risk. Screening labs for metabolic risk factors (lipid panel, liver enzymes and A1c and/or glucose) are recommended starting at age 10 if obese (or overweight+risk factors). To promote healthy behaviors, refer to resources like the YMCA ACT! program – ACT! programs are enrolling this winter for 8-14 year olds around our area. We can also refer to SCH Wellness Clinics for multidisciplinary weight management from age 2 through adolescence. When metabolic problems are identified, see this article on treating comorbidities.
  5. What is the role of physical activity? For children at all weights, regular physical activity reduces the likelihood of comorbidities, even without decreasing BMI. It’s important for us to emphasize helping kids and parents find ways to be active and enjoy movement, no matter their body size.

2018-19 TOW #21: Firearm injury prevention

This week’s topic seems particularly timely given the overwhelming physician response to the NRA’s “stay in your lane” tweet last week. We have many resources locally including the incredible Dr. Fred Rivara, a nationally-renowned researcher on firearm injuries and prevention. The Seattle Children’s community benefit team and REACH pathway residents have worked to develop local resources and events.

Materials for this week:

Take-home points for firearm safety:

  1. Statistics: 1 in 3 homes in the US with children have firearms, many of which are not locked. 80% of unintentional firearm deaths of kids under 15 occur in a home. 64,000 adults in King County with a firearm in or around their homes reported storing their gun(s) loaded and unlocked. The safest thing is not to have a firearm in your home, as it is 43 times more likely to be used to kill a family member or friend rather than be used in self-defense. In a case-control study done by Grossman et al., storing firearms locked, unloaded, or separate from the ammunition was associated with significantly lower risk of unintentional and self-inflicted firearm injuries and deaths among adolescents and children.
  2. Many depressed teens die from suicide by firearms. If you are tight for time and cannot screen for firearms in every clinic wellness visit, be sure to include specific counseling in visits with depressed teenagers. Come up with a safety plan for gun storage with the parents, and offer resources such as 1-800-273-TALK from the suicide prevention lifeline.
  3. What to offer for gun safety? There are 5 main types of locking devices: lock box, gun vault or safe, cable lock, trigger lock, and personalized lock. Generally, we should avoid devices that use keys. Visit www.lokitup.org for information about how to store firearms. We need to help advise that the safest way to store guns is unloaded, locked, and out of reach of young children and teenagers! Consider using a statement like: “Having a loaded or unlocked gun in your house increases the risk of injury or death to family members, whether by accident or on purpose. I urge you to store your unloaded guns in a locked drawer or cabinet, out of reach of children.”
  4. How do we advise parents and firearm safety? We can counsel parents to ASK other parents about guns in their home before sending over their child to play: http://askingsaveskids.org/ Suggested wording includes:  “Knowing how curious my child can be, I hope you don’t mind me asking if you have a firearm in your home and if it is properly stored…” For family members, this might include: “[Mom, Dad] this is awkward for me and I mean no disrespect. I am concerned Susie will find one of the firearms in your home when we visit. Do you keep them locked up with the ammunition stored separately?”
  5. Does counseling work? Several studies have found counseling in office visits to be associated with improved safe storage of firearms. A standard screening question followed by a 20 second firearm storage safety message led to counseled families being 2.2 times more likely to practice safe firearm storage techniques. Likewise, Barkin et al. found that brief office-based counseling increased the use of safe storage.

2018-19 TOW #20: Tobacco Exposure and Cessation

This week’s topic is tobacco exposure and smoking cessation in honor of the Great American Smoke Out coming up next week on Thursday November 15th. The American Cancer Society designates the 3rd Thursday of November (the Thursday before Thanksgiving) each year to encourage smokers to quit or set a plan to quit. We have a role as pediatricians to help parents and patients with reducing smoking and secondhand smoke exposure. We can practice compassionate, trauma-informed care with a supportive stance using motivational interviewing to respectfully help with smoking cessation.

Materials for next week:

 

Take-home points:

  1. How many children are exposed to secondhand smoke? How does teen smoking relate to adult smoking? More than half of US children have secondhand smoke exposure (based on biological samples of population data). Approximately 90% of adults who smoke began smoking prior to age 19 (which is why tobacco companies target ads to youth…) Each day, an estimated 4400 American teenagers try their first cigarette. 80% of youth who smoke will continue to smoke into adulthood.
  2. How does secondhand smoke exposure affect children? Strong evidence from epidemiologic and basic science research demonstrates that prenatal and childhood exposure causes respiratory illness in children. Based on observational data, tobacco smoke exposure is also associated with non-respiratory illnesses, such as SIDS, ADHD and lower cognitive scores.
  3. What’s the evidence that discussing tobacco exposure with parents is helpful? Randomized controlled trials in adults and the Clinical Effort Against Secondhand Smoke Exposure (CEASE) study have found that asking adults about their smoking and offering assistance with quitting or referral to the quitline is effective.  Parents report they expect their pediatrician to ask about smoking but only about half of parents say they have been asked about smoking. The US Preventive Services guidelines recommend we assess secondhand smoke exposure for children at each visit and refer to quitlines for parents who are smoking. All states have quitlines with counselors who are trained specifically to help smokers quit. The quitline number is meant to be remembered: 800-QUIT-NOW (800-784-8669). There’s also an online chat via the National Cancer Institute.
  4. What are the strategies for discussing smoking with parents? We are recommended to Ask, Assist and Refer. “Is your child around anyone who smokes?” is a neutral way to open up the conversation. If the parent is smoking I often follow-up with “How are you feeling about smoking?” as an MI-style question to elicit where they might be in stages of change. We can explore past quitting attempts and what worked, as well as reasons to quit to bring out change talk. Don’t forget about using 1-10 scales to assess readiness and confidence. If they are not ready to quit, we can explore strategies they are using to decrease exposure for their children (outside only, smoking jacket that is removed, washing hands, etc.) This is a great stat to highlight: Getting help through medications and counseling doubles or even triples the chance of successfully quitting. 
  5. What are the risks of vaping? Nicotine use is now increasingly in e-cigarette form, especially among teens. Teens perceive these as safer, but electronic nicotine delivery systems (ENDS) have been found to contain numerous toxins and carcinogens harmful to users and those exposed to secondhand emissions. E-cigarettes have not been found to help people quit cigarettes, but have been associated with leading to use of regular cigarettes, especially among teenagers.

2018-19 TOW #19: Acute Asthma

It’s the time of year when our clinics and the ED are starting to see more kids with viral-induced asthma exacerbations, so it’s an opportune time to review the guidelines and resources to address these. The REACH pathway residents have provided some helpful materials, which I have included below. Locally we also have the wisdom of the great Dr. Jim Stout, faculty at Odessa Brown, who has been a national leader in asthma quality of care research.

This week’s teaching materials:

Take-home points for acute asthma management:

  1. Epidemiology: the CDC estimates that 8.3% of children have asthma, making it one of the most prevalent diseases of childhood. Rates are higher among blacks, certain Hispanic groups, and those in poverty. Among those with asthma below age 18, 57.9% report having one or more asthma attacks, so the majority of kids with asthma will be treated for exacerbations.
  2. Severity guides treatment: Determining severity is based on many components including level of dyspnea, respiratory rates, heart rates, extent of wheeze, and work of breathing (accessory muscle use). These factors are combined in generating respiratory scores used at Seattle Children’s Hospital (SCH), such as in the SCH asthma pathway.
  3. Initial treatment: For moderately severe symptoms, give albuterol MDI 8 puffs (MDI strongly preferred, but if not available, give 5mg/3ml nebulized), start dexamethasone (0.6mg/kg, max of 16mg), and repeat in 24 hours. Alternative steroid dosing for moderate to severe asthma is prednisone or prednisolone (2 mg/kg/day) for a total course of 5-10 days, depending on severity and history.
  4. Education is critical: as we know, education about asthma is so important to families’ understanding and implementation of treatment. It’s important to review and update asthma action plans during exacerbations. Families should receive coaching and should be able to demonstrate use of MDIs with a valved holding chamber (VHCs or “aerochamber”). There are great written resources and videos out there on avoiding triggers through the NW Clear Air Agency. Families in Seattle/King Co are eligible to receive a free home health assessments through the American Lung Association. Most families do not know about this great program, so referral is key.
  5. Provide follow-up: it’s important to have follow-up within a few days (in person for more moderate cases, or maybe by phone for milder cases) to tailor medications. Follow-up on environmental triggers is also important. The Washington Medical-Legal Partnership (MLP) has great sample letter templates we can use to help families notify landlords of needed repairs, such as improving ventilation, removing mold or insects. If you need additional assistance, remember to refer patients via the Washington MLP at Seattle Children’s Hospital (patients are eligible if they are patients at SCH).

TOW #19: Asthma diagnosis and management

This week our REACH pathway R2s shared some asthma management tips and tricks for morning report and featured R2 Bryan Fate’s new hit song “IHELP You”! As one of our most common childhood conditions, asthma diagnosis and outcomes highlight the effects of social determinants of health and the resulting health disparities that unfortunately exist. Our residents reminded us how we can recognize and address social needs through screening, referral and use of support systems. The IHELP mnemonic is used to screen for Income, Housing, Education, Legal/Literacy and Personal safety needs that affect overall health, including asthma. We want to provide effective care for children of all backgrounds and to recognize and address the powerful influence of social factors on health. Let’s keep this in mind as we discuss asthma.

A BIG thank you to Dr. Cathy Pew our intrepid gen peds team leader at Neighborcare – Meridian who tackled being lead author for our local outpatient asthma management guidelines and to the wise Dr. Jeff Wright, emeritus faculty, who initially designed the algorithms to accompany them.

Materials:

Asthma Diagnosis and Management take-home points:

  1. Epidemiology: Asthma rates are increasing every year in the US. Asthma affects 1-2 out of 10 children in the US and rates are even higher among black and Hispanic children. From 2001 through 2009 asthma rates rose the most among black children, almost a 50% increase.
  2. Asthma diagnosis and management is based on age, severity, and level of control. “Severity” is the intrinsic intensity of the disease process, which is based on impairment and risk. Severity is classified as “intermittent” or as “persistent” with mild, moderate, or severe levels. “Control” refers to the degree to which manifestations of asthma are minimized and the goals of therapy are met. This is classified as “well controlled,” “not well controlled”, or “very poorly controlled.” To help make this diagnostic process easier, please refer to our UW Division of General Pediatrics outpatient clinical guidelines for asthma which are based on the 2007 NHLBI guidelines and include flow diagrams for 0-4 yo, 5-11 yo and 12 and older (as above).
  3. We use a step-wise treatment to help manage asthma. The National Asthma Control Initiative outlines 6 priority messages for clinicians to help control asthma:
  4. To reduce environmental exposures for children, there are a number of resources we can use. Key resources locally include the American Lung Association home health assessment program and the King County asthma program, both of which have home visiting programs that we can refer families to that will help identify environmental exposures. The Medical-Legal Partnership is also helpful to access the legal system to ensure environmental triggers are minimized in rental properties where children live.
  5. Be sure to review your clinic’s management approaches and tools including action plans, EMR tools, screening questionnaires, and spirometry options. For clinics using EPIC, there is a great smartset for asthma that Dr. Sheryl Morelli helped champion based on the outpt guidelines.

Thanks for all you do to care for our community’s children and address their needs at many levels.

TOW #18: Lead screening

We are continuing our advocacy-related theme topics over the next few weeks during the REACH Pathway month. There has been tremendous advocacy done by pediatricians to help prevent and address lead toxicity. Most recently this has included the inspiring work by pediatrician Dr. Mona Hanna-Attisha in Flint MI who was one of the first people to raise awareness about dangerous lead levels in the water supply 2 years ago. We are fortunate to have two prominent environmental health pediatricians, Drs. Catherine Karr and Sheela Sathyanarayana, in the general pediatrics team here at UW who do research and advocacy to keep children safe from toxins. They both contributed to this teaching topic.

Materials for this week:

Take-home points for lead screening

  1. What is a safe blood lead level (BLL)? Based on strong research evidence, no measurable BLL is considered safe. Neurotoxicity associated with lower BLLs has been established by overwhelmingly consistent evidence from meta-analysis, so primary prevention of lead exposure is paramount. All detectable BLLs are reportable in WA State and the health department follows up with all BLLs > 5 mcg/dL.
  2. Why screen for lead? While lead is toxic to multiple body systems, the developing brain is particularly vulnerable. Most lead toxicity in the US is sub-clinical, only found on blood testing. Even low levels (<10mcg/dL) may be associated with behavioral problems (such as attention, aggression) and learning difficulties. Children aged 9-24 months are highest risk due to normal exploratory behavior – crawling, teething, putting non food objects in the mouth. Absorption across the gut is greater in children than adults.
  3. What are the sources of elevated lead levels? Ingestion of lead-containing dust or soil is the highest source, usually from old paint in homes built before 1950, but up through 1978, and homes from these eras being remodeled. As we have learned from Flint MI, lead is also in water sources, from contaminated water and old pipes. There are also newer sources of lead in imported products including candies, food, spices, make-up, and ceramics.
  4. Who should receive blood lead testing? In WA state, the 2016 guidelines identify children with these risk factors: 1) Lives in or regularly visits any house built before 1950 or built before 1978 with recent or ongoing renovations or remodeling, 2) From a low income family (<130% of the poverty level). (Federal law mandates screening for all children covered by Medicaid), 3) Known to have a sibling or frequent playmate with an elevated blood lead level, 4) Is a recent immigrant, refugee, foreign adoptee, or child in foster care, 5) Has a parent or principal caregiver who works professionally or recreationally with lead, 6) Uses traditional, folk, or ethnic remedies or cosmetics. Unfortunately, screening questionnaires have not reliably identified kids, as one of our residents found for a topic review at Harborview, so when in doubt, screen.
  5. What do you do with an elevated level? The PEHSU provides a summary of key next steps based on BLL results on their website. Next steps will include evaluation for anemia/nutrition since this may impact lead absorption, as well as determining the need for imaging or medical management.